Morris Panner, Ambra Health Chief Executive Officer

Patients have never been more vested in their own health journey. With new coronavirus infections soaring again across much of the country, it makes sense that we are now hyper-vigilant about the state of our own health.

One need not look far for evidence of this shift in behavior. From new consumer-initiated services that bypass the traditional route of getting referred by one’s primary caregiver for additional testing to receiving results on-demand in a patient portal, patients are hopping into the driver’s seat. In a post-pandemic world are we going to see patients expecting more access to their health data on-demand? 

A healthcare system under transition has meant that more than ever the patient is at the center at every stage of their journey -- from physician, to radiology, to follow-up. But, for radiologists, this shift can pose a significant challenge, because their role has traditionally meant contact mostly with other doctors, with limited patient engagement.

However, radiologists are increasingly changing how they work in order to engage with patients more. With the growth of patient and physician portals, and increasingly activated patients, there are more opportunities for contact than ever.

Patient-centered healthcare initiatives have been underway to empower patients to take more responsibility for their healthcare for years, but the reality has rarely met the enthusiasm. In 2015, a 

study in Perspectives in Health Information Management

 found that approximately half of healthcare providers surveyed who offered patient portals reported that less than 5 percent of their patients actually used it. As of 2018, little had changed: 

 found that only 52 percent of patients were offered online access to their records of which 28 percent had actually viewed them. This level of usage is truly abysmal considering how important online and mobile services are to all aspects of our daily lives.

 are nudging institutions to adopt more tech-friendly practices to engage patients directly and share vital health information, but adoption has been slower than in other industries. This could be due to the fact that the healthcare industry has been slower to build healthcare technology at a consumer-grade or the reality that so many silos exist that it’s more burdensome for the patient to take charge than just let the system work as it always has. Interoperability and standardized data criteria for API developers are the key factors for ensuring effective technological innovation.

The pandemic has ushered in a new sense of urgency for patient-centered care. In the first half of 2020 alone, U.S. digital health companies raised a record-setting $5.4 billion in venture funding 

. This demonstrates there’s never been a greater need—or demand—for technology-enabled healthcare.

Many of the previous barriers to tech adoption rapidly dissolved out of necessity as doctors turned to video conferencing for consultations, labs launched more direct-to-consumer offerings, and patients equipped themselves with medical monitoring devices like pulse oximeters in their homes. It will be paramount that the healthcare industry and technologists alike prioritize consumer demand when considering innovation. With all the complexity in the healthcare system and a patient’s own needs, providing more information without context and within siloed applications may be counterproductive.

The next challenge will be ensuring that with all of this information going directly to the patient, they will continue to have sufficient access to a trusted medical partner to provide actionable advice. In the past, radiologists have broadly been “the doctor's doctor”. But, increasingly activated patients, who are looking to participate more in their care, are looking for access to their complete medical records— from test results to imaging results. While most patients want to receive results directly from their referring physicians, many also want to see their radiology reports and images, too.

Ultimately, patients are looking to receive results from more channels and get more data points. Comprehensive electronic health records, easily accessible by the patient, will be essential. 

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As the desire to know more about individual medical records grows, easy accessibility for patients will be vital.

Will the Covid-19 Pandemic Accelerate Patient Access to Data?

Should I go to the doctor? This is a recurring question on the minds of those due for routine appointments, screenings, or maybe even a simple check-in. So far, the public has largely heeded warnings to delay routine screenings and move as many consultations as possible to a virtual setting. While these are all valuable behaviors to reduce the spread of COVID-19, there are certain exams that cannot be done virtually, many of which include routine imaging screenings.

Routine screenings for colon, breast, and cervical cancers have dropped between 

 compared to the previous three years, according to medical records software provider, Epic.

Just how important is routine imaging? A few years ago, the 

 by the American Cancer Society noted a 39-percent reduction in breast cancer deaths since the 1980s due to earlier detection and diagnosis. Screening with low-dose spiral computed tomography (LDCT) has also been shown to reduce lung cancer mortality by about 20 percent compared to standard chest X-ray among current or former heavy smokers ages 55-to-74. Researchers have also been studying the possibilities of other imaging exams for screenings of traditionally hard-to-treat cancers, such as pancreatic and ovarian cancers.

Over the last few years, recommendations have already become increasingly confusing with The U.S. Preventive Services Task Force (USPSTF) changing 

, including raising the suggested annual mammography age to 50 for women instead of the previously recommended 40. Their concern was that false positives led to unnecessary and often stressful biopsies for women. However, many physicians and radiologists strongly disagree with these recommendations. Over 

 of physicians still suggest that routine mammography screenings should begin at age 40.

So, if these imaging exams are so valuable, how long exactly can you wait for routine screenings? The information here is highly muddled. Currently, the American Cancer Society 

 that routine screenings should be skipped. They say a delay of one-to-two months is okay for those at average-to-low risk. However, those at high risk due to a family or personal history of cancer should discuss their case with their physician. Some screenings can even be done at home if needed, like colorectal screenings, using an at-home test. Non-imaging related exams like physician, well-woman, and annual skin cancer screening can often be conducted virtually initially and, then, a determination can be made on a date for an in-person visit.

Healthcare technology vendors can help retain imaging value while reducing volume by providing patients with enhanced access to past imaging and allowing them to share data with providers through patient portals, image-enabled EHR portals, and more. The ability for a patient to send and consult with a physician on prior imaging may allow both parties to make a more educated decision on the timing of future exams.

In some cases, certain risk factors might push a physician to encourage someone to stay at home and put off routine exams for longer. Patients should always consult with their own physician on their personal health history and weigh the pros and cons of routine imaging. However, as imaging centers increasingly take new precautions on the safety of their facilities and add new technology that could reduce in-person interaction where possible, healthy patients will likely be able to resume necessary and routine image screening.

With safety precautions in place, imaging centers can consider bringing in healthy patient for screenings.

Assessing Value Versus Risk for Routine Screenings

A lack of available COVID-19 testing in the United States has many asking the question, could we be using CT scans to rapidly diagnose patients instead? This question has attracted both attention and conflict.

 emerging from Wuhan showed that 97 percent of cases with a COVID-19 diagnosis had CT findings consistent with pneumonia and shared that, “CT imaging has high sensitivity for diagnosis of COVID-19.” However, a recent critical review in the 

 called for CT imaging to be used only in cases of complex pneumonia. Currently, the authors believe that we do not have enough data to support the use of CT scans for diagnosis and that using the machines can pose additional risks for healthcare workers on the frontlines or potentially expose healthy patients to the disease.

The authors shared, “These risks include: overuse of hospital resources, including the use of protective gear that is already limited in availability but is required to safely perform CT studies; clustering of affected and unaffected patients in imaging departments, thereby potentially increasing risks of disease transmission and exposure among staff performing the examinations; patients for other indications because of increased use of CT scanners to evaluate cases of suspected COVID-19.”

The American College of Radiology agrees and has set new 

 and guidelines around appropriate imaging techniques. These include that CT scans should not be used for diagnosis and used sparingly for patients who have pneumonia or other critical symptoms. The ACR believes that a normal CT may not mean that a patient does not have COVID-19 and vice versa. They also encourage the use of portable scanners when possible so that patients can be imaged directly in the ER or ICU rather than traveling to radiology.

Using portable scanners poses an additional challenge to facilities who now must ensure that they have a mechanism of transferring imaging from portable scanners directly into radiology PACS. While some facilities may already have cloud-based imaging workflows in place, others are still heavily tied down by siloed systems.

Radiology departments should remain prepared for an influx as new data is constantly emerging and confusion in hospital policies could lead to patients appearing through their doors looking for a diagnosis. Researchers from the University of Southern California outlined the disaster 

 that departments should take and said, “It is clear that the radiology department will need to be ready for the COVID-19 outbreak. Major factors that will affect radiology throughput are transportation, cleaning equipment, proper usage of personal protective equipment, and interpretation of radiologic examinations. Having an MCI plan in place for a viral outbreak will protect patients and staff and ultimately decrease virus transmission. The use of simulations will help identify throughput and logistical issues.”

Some imaging centers faced with lower volumes are even considering opening COVID-19 only imaging centers. As these centers open across the country, new data could emerge to support the benefits of imaging for testing purposes. Artificial intelligence may also enable more rapid imaging analysis going forward.

At UC San Diego Health, physicians are using AI tooling in a new 

 on imaging analysis powered by Amazon Web Services.

“We would not have had reason to treat that patient as a suspected COVID-19 case or test for it, if it weren’t for the AI,” said Christopher Longhurst, MD, chief information officer and associate  chief medical officer for UC San Diego Health. “While still investigational, the system is already affecting clinical management of patients.”

The use of imaging for COVID-19 diagnosis will continue to evolve and radiology departments must be prepared for a potential influx of patients, new safety protocols, and guidelines regarding appropriate measures, dosage, and productive usage.

Departments and practices must be prepared for the impending influx of imaging.

The Continuing Evolution of CT Use During COVID-19

Discussing the importance of virtual care and telehealth services, including teleradiology, is nothing new. Previously, many of these conversations fell into the bucket of “want to have” rather than “need to have,” especially, for those of us fortunate to have top-tier medical facilities nearby. Today, as COVID-19 changes the way many of us think about daily life, the ability to access a medical professional or service virtually suddenly seems quite urgent. Traditional concepts of geography (which often affected patients in rural areas the most) may now apply to as short of a distance as one subway ride.

A patient that is a regular visitor to their physician’s office or their local hospital is often a patient who is also most at risk of developing a serious COVID-19 infection. Physicians should consider utilizing telehealth for these patients to reduce their time spent in public. While there is a stereotype that older patients may not be as technologically savvy, 

 have shown that Boomers are, in fact, very much in favor of digital health and are interested in using technology to facilitate reminders, after-hours visits, daily support, classes, and appointment follow-ups.

On Monday of this week, the Trump administration announced the expansion of telehealth services for Medicare beneficiaries. This includes paying doctors and facilities for telehealth services in replacement of traditional hospital visits, medical practice visits, and even mental health care in some cases.

“This action is a part of our broader effort to ensure that government requirements, [and] rules and regulations don’t get in the way of patient care during an emergency,” said Seema Verma in a press conference at the White House on Tuesday. “These services can be provided in a variety of settings, including nursing homes, hospital outpatient departments, and more.”

Traditionally, HIPAA has acted as a complex barrier when it came to telehealth. However, the new guidelines have broken down many of these same barriers, allowing greater flexibility for physicians to use their own phones and conduct virtual “check-ins” of patients with high-risk conditions. Guidelines still urge that practitioners avoid communications on social media applications to reduce privacy concerns.

Many facilities have already had success with telehealth programs. At WakeMed Health and Hospitals in North Carolina, Valerie Barlow, Vice President of Clinical and Support Services said, “61 percent of patients who used WakeMed Virtual Urgent Care and completed the survey would have gone to an urgent care facility had they not had access to this telemedicine option, (and) 14 percent of patients who used virtual care and completed the survey would have gone to an emergency room had they not had access to the service.”

Virtual services provide a solution to reducing physician burnout and keeping only the most at-risk patients in hospitals.

Virtual solutions can also offer physicians a method of educational collaboration. In the UK, The British Society of Thoracic Imaging (BSTI), in conjunction with Cimar UK’s Imaging Cloud Technology (

 to upload and refer imaging of patients with either confirmed or suspected COVID-19. All cases are automatically anonymized by CIMAR at the point of upload. Access is public, and the platform already has over 5,000 views despite just being live for a few days.

Access to healthcare needs to be virtual more than ever. Facilities and providers must be open to accepting creative solutions, and technology vendors should work together to enable these new and exciting workflows. Together, we can all work to offset the burden on our healthcare system during this challenging time.

Remote services and providers can help control the spread of infection.

Author | Morris Panner, Ambra Health Chief Executive Officer

Articles

Will the Covid-19 Pandemic Accelerate Patient Access to Data?

Assessing Value Versus Risk for Routine Screenings

The Continuing Evolution of CT Use During COVID-19

COVID-19 Spotlights Need for Virtual Services, Including Teleradiology